1. S Grantham-McGregor Centre for Health and Development, Institute of Child Health, University College London Child development in developing countries

2. The Lancet series: The development of children <5 yrs in developing countries (Grantham-McGregor et al 2007, Walker et al 2007,P Engle et al 2007) International Child Development Steering Group: S Grantham-McGregor, P Engle, M Black, J Meeks Gardner, B Lozoff, T Wachs, S Walker, Paper 1&2, Y B Cheung, S Cueto, P Glewwe, Richter, B Strupp, J Meeks Gardner, GA Wasserman, E Pollitt, JA Carter 1.The size of the problem 2.The causes

3. Overall Aims of Lancet Series To increase awareness of the problem of poor development in early childhood in low resource countries. To make the promotion of optimal child development an international priority. Bring together academics from many different disciplines from universities, UN agencies and NGOs to develop a consensus for action.

4. Aims of paper Estimate the size of the problem Identify the location of affected children Estimate cost and consequences Factors causing poor development

5. Why focus on early childhood?  Brain development most rapid and vulnerable from conception to 5 years  Insults and interventions can have lasting effects  Interventions are more cost effective than at other ages  Cognitive ability & behaviour on entry school progress

6. Sensory- motor Cognitive- language Social- emotional Domains of Child Development

7. Major problem with estimating numbers of affected children Insufficient data on early cognitive ability for most developing countries to estimate prevalence

8. Need to use risk factors as indicators of poor child development to assess prevalence 1. Stunting (<-2SD) 2. Poverty<$1 per day ( adjusted for purchasing power by country, World Bank 2005)

9. Requirements of indicators Standardised measures across countries Global data available Relevant in most countries Consistently related to poor child development and school achievement in developing countries ?

10. Stunting in children > 28 studies X-sectional associations between stunting & poor cognition or school achievement

11. Longitudinal data essential Jamaica Walker South African Richter, Norris Phillipines Cebu study Uganda data Family Life Study Brazil Victora, Barros, Damiani, Lima, Gigante, Horta Peru Berkman, Lescano Guatemala Martorell

12. Cognitive or schooling deficits associated with moderate stunting <3yrs in 7 longitudinal studies Philippines S Africa Indonesia Brazil Peru Jamaica Guatemala 7yrs 9yrs 17-18yrs18yrs 15yrs 18-25yrs SD scores

13. Reasonable to use stunting as an indicator of poor child development Conclusion

14. Poverty <1 per day >60 X-sectional studies showed associations with wealth and school achievement or cognition

15. Later cognitive deficits associated with being in the lowest wealth quintile <3yrs in 5 longitudinal studies (SD scores) Philippines Indonesia S Africa Brazil^ Guatemala* ^Grades attained *boys 15yrs7yrs 18yrs 18-26yrs

16. Reasonable to use poverty as an indicator of poor child development Conclusion

17. Millions of children < 5y not fulfilling their potential in development (WHO, 2006; UNICEF 2006) Stunted Poverty Disadvantaged 156m 126m 219m (39% of children <5y) Stunted + Poverty not stunted

18. % of disadvantaged children <5yrs by region

19. Limitations Other risk factors not included Cut off for poverty uncertain Estimate for numbers of children based on poverty rates for total population Underestimate

20. 1.Deficit in grades attained (Brazil) 2. Deficit in learning per grade (Phillipines, Jamaica) 3. Estimate total deficit (1+2) 4. Using estimate of 9% loss in income per grade (53 countries Psacharopoulos 2004, Duflo 2001) 20 % loss of yearly adult income Loss of yearly adult income

21. Deficit in grades attained Deficit in learning per grade % loss of yearly adult income Mean % Stunted0.912.022.2 19.8% Poor0.71???5.9 Stunted & poor 2.152.030.1

22. Conclusion Loss of children’s potential is an enormous problem affecting >200million It has economic and social costs both to individual and nations

23. Risk factors affecting child development in low resource countries

24. Selection criteria Modifiable by interventions or public policy Affect large number of children less than 5 years in developing countries Risks with little information from developing countries excluded

25. Four main risks  Chronic undernutrition leading to stunting  Iodine deficiency  Iron deficiency anemia (IDA) Inadequate cognitive stimulation

26. Deficits at 17 yrs in Jamaican children stunted before 2 yrs IQ, vocabulary, cognition school achievement /drop out fine motor depression, anxiety, attention deficit, self esteem, hyperactive, oppositional Walker et al 2005, 2006

27. Inadequate cognitive stimulation or learning opportunities A biological insult

28. Mean Corticosterone Levels Pre & Post Stress in Non- handled, Handled and Maternally-separated Rats Plotsky & Meaney 1993 µg/dl Pre-stress Time (min) (n= 8 per group)

29. Intervention studies 15 of 16 intervention studies providing cognitive stimulation show benefits to development Centre based or home based: Effect size 0.5-1 SD Lancet paper2

31. Effects of visiting frequency in disadvantaged children DQ Powell & Grantham-McGregor, 1989 fortnightly monthly no visits 94 98 102 106 110Pre-testPost-test weekly

32. McKay et al, 1979 Cognitive ability Cognitive ability at 7 years by duration of center based intervention; Colombia 0 123 4 Periods of intervention

33. Interventions with stunted children DQ non-stuntedcontrol Grantham-McGregor et al, 1991 both Rxs supplemented stimulated

34. Sustained: Benefits at 17-18 Years From Early Childhood Stimulation in Stunted Children Standard scores P value Walker et al, 2005 ********** *** *** nsnsnsns *p<.1; **p<.05, ***p<.01

35. Sustained: Benefits at 17-18 years from stimulation in early childhood in stunted children Standard scores ******ns**nsns* P value Walker et al unpublished *p<.1; **p<.05

36. Consistent concurrent benefits to child’s DQ Consistent concurrent benefits to child’s DQ Benefits greater in : Benefits greater in : more intense, longer, include nutrition Sustainable cognitive,education and mental health benefits at 17-18yrs Sustainable cognitive,education and mental health benefits at 17-18yrs Summary of stimulation studies

37. Conclusion: Good evidence for 4 main risks  Chronic undernutrition leading to stunting  Iodine deficiency  Iron deficiency  Inadequate cognitive stimulation

38. Other risk factors Risk factors with consistent epidemiological evidence showing association with development Lack of interventions with evaluation of effectiveness

39. Other risks identified Small for gestational age Malaria Maternal depression Exposure to violence Exposure to environmental toxins

40. Multiple risks in early childhood and achievement scores in adolescence Gorman and Pollitt, 1996 Risk factors

41. Mean Developmental Quotients on Griffiths Test DQ Age months Urban middle class n=78 Urban poor n=268 (Walker et al)

42. Poverty Poor care and home stimulation Maternal stress/ depression Low education Poor cognitive, socio-emotional development Stunting & wasting, iodine & iron deficiency, diarrhoea, infections Poor school achievement Poor sanitation, Food insecurity Poor hygiene, feeding practices, care-seeking

43. national economy

44. Countries with highest % of children < 5y who are stunted in Latin America & the Caribbean (UNICEF 2006) %

45. Types of evidence 1.Randomised trials and intervention studies 2.Prospective cohort studies 3.Associational studies (with control for confounders)

46. Vocabulary scores by SES quartiles in 36 to 72 month old children Equador Paxson and Shady 2005 age in months

47. Why health services? Only service accessing children in first 3 years Already has an infrastructure Development an integral part of health Poor health & nutrition poor development Mothers enjoy and can facilitate other activities We cannot wait for new services

48. Why psychosocial stimulation interventions? Malnourished children do not catch up with nutrition aloneMalnourished children do not catch up with nutrition alone Stimulation changes brain function in animalsStimulation changes brain function in animals Adoption studies show vast improvementAdoption studies show vast improvement In USA disadvantaged children have shown sustained benefitsIn USA disadvantaged children have shown sustained benefits

49. IQ scores of stunted and non-stunted Jamaican children from age 9-24 mo to 18 y Non-stunted Stunted. -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 Griffiths on Enrollment (9-24 mo) Griffiths (33-48 mo) Stanford- Binet (7-8 y) WISC-R (11-12 y) WAIS (17-18 y) SD score Walker et al 2005

50. 7 longitudinal studies of stunting <3yrs & later function Country Follow-up age Outcome Indonesia 7 cognitive test S Africa 7 cognitive test Peru 9 IQ Philippines 15 schooling Jamaica 17-18 schooling, IQ Brazil 18 attained grades Guatemala 18-26 schooling, IQ